Healthcare Provider Details

I. General information

NPI: 1255795761
Provider Name (Legal Business Name): LOVELACE MEDICAL SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 ELM ST NE
ALBUQUERQUE NM
87102-2500
US

IV. Provider business mailing address

505 ELM ST NE
ALBUQUERQUE NM
87102-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberA-0996
License Number StateNM

VIII. Authorized Official

Name: ROBERT MENDOZA
Title or Position: PHYSICAL THERAPY ASSISTANT
Credential: PTA
Phone: 505-515-6767